A new study on the Alexander Technique and knee pain was published last month in the journal BMC Musculoskeletal Disorders. 21 subjects with knee osteoarthritis were each given 20 Alexander Technique (AT) lessons. After their lessons, they not only reported a 50% reduction in pain, but showed significantly less co-contraction in their leg muscles during walking. The entire study is available online to read here.

When I first read the study, I was struck by its size. 21 subjects (the study also used 20 healthy individuals as a control) didn’t seem to be that many. I’ve grown used to reading the larger randomized control trials, like the ATEAM back pain study published in the British Journal of Medicine in 2008. The ATEAM study involved 579 subjects. My assumption was that the larger the study, the more robust the findings. What could a study of 21 people really tell us?

The design of a study, however, depends on its purpose. The ATEAM back pain study—or last year’s ATLAS Annals of Internal Medicine study of whether AT or acupuncture are effective in treating chronic neck pain—is an example of a clinical trial, and such trials need to be large for a number of reasons. Subjects are divided into multiple groups. For example, the ATEAM back pain study randomly assigned subjects to groups that took 6 AT lessons, 24 AT lessons, 6 massages, or a control. Such large trials also deal with conditions that tend to have nebulous causes. The idiopathic back pain diagnosis studied in the ATEAM trial is just the technical way of saying, “your back hurts and we don’t know why.” The measurements in clinical trials—like self-report—are often subjective, and the clinical effects of an intervention are usually small. So a clinical trial needs to be large to show statistical significance.

Such large studies, though, can shift clinical practice—what doctors’ prescribe when they’ve diagnosed a patient with idiopathic back pain or chronic neck pain. As such, they also tend to generate headlines in the popular press. Last year’s ATLAS neck pain study was reported on by Time, NPR, Fox News Health, and Harvard Health, among others.

The current study of subjects with knee osteoarthritis is not a clinical randomized control trial. It is basic research, in a laboratory environment that is more controlled than usually possible in large clinical trials. It also uses more concrete measurement. As such, it can establish robust findings with many fewer subjects. And the purpose of such basic research is not only to establish whether the Alexander Technique might be an effective way to treat knee pain, but why. It’s an exciting window into researchers at work. Let’s unpack the study.

Why do we hurt?

Chronic pain is a surprisingly mysterious thing.

Take knee osteoarthritis. Knee osteoarthritis is a condition where the cartilage that cushions the bones of the knee joint starts the wear down. In this study, the 21 participants all had received an x-ray diagnosis of knee osteoarthritis. An x-ray doesn’t show cartilage: but it will show that the space between bones has narrowed, indicating osteoarthritis. Blood work can further confirm that the condition isn’t systematic (as in rheumatoid arthritis).

It sounds obvious, but if you have knee osteoarthritis, your knees usually hurt. But why? It has long been assumed that the pain that accompanies knee osteoarthritis is the result of the breakdown of cartilage in the joint. Less cushioning equals more pain. But researchers have been unable to show a relationship between the severity of pain and the degree of cartilage loss. Some people with minor cartilage loss in the joint suffer a great deal of pain. Others with major cartilage loss experience little discomfort—they may not even know they have the condition. The same is true in some forms of chronic back pain: there are individuals with significant damage to their vertebrae or intervertebral discs, yet experience little pain, and vice versa.

This new study explores two possible explanations for the pain that accompanies knee osteoarthritis.

1. Is pain a self-fulfilling prophecy?

One possibility is that the patients with knee osteoarthritis become more sensitive to pain. You might call this the “self-fulfilling prophecy” explanation of pain. The idea is that people with chronic pain begin to anticipate that pain, and therefore experience more pain. Previous research has found that Cognitive Behavioral Therapy or mindfulness meditation can reduce a heightened sensitivity to pain in subjects with osteoarthritis or fibromyalgia.

While the subjects in this new study reported a significant reduction in pain after their Alexander Technique lessons, the researchers didn’t find evidence that their Alexander Technique lessons had reduced their sensitivity to pain. The research didn’t disprove the idea that subjects with osteoarthritis might have a heightened sensitivity to pain, just that the benefits of AT didn’t seem to function along those lines. (The authors caution that the study might be too small to know for sure.)

2. Is pain the result of how you move?

The other possible explanation for knee pain that this study explores is that the patients with knee osteoarthritis use excessive co-contraction of their leg muscles during walking and other everyday activities. To understand co-contraction, it helps to know a bit about how muscles work.

Muscles often work in pairs. The muscle that’s doing the work is called the agonist. The muscle that is allowing the work is called the antagonist. Take a simple action like the biceps curl. When your biceps works to close the elbow joint, its antagonist, the triceps, releases. When the triceps works to open the arm at the elbow, the biceps releases. The biceps and triceps are an antagonistic pair.

Your hamstrings and quads muscles in your legs are an antagonistic pair as well. Check out this animation of the muscles that are active during walking. While walking is a much more complicated movement than a biceps curl (this animation also includes the iliopsoas, the glutes, and muscles of the lower leg called the tibialis anterior and calf) you can see the quads and hamstrings taking turns during the gait cycle. If you find the action of the muscles hard to follow, watch the bars of activity on either side of the walking figure.

[This animation was done for Aberystwyth University in Wales. It is not associated with the AT and Knee Osteoarthritis study that is the subject of this blog post.]

Co-contraction is when muscles that are usually antagonistic activate simultaneously. In everyday activity, co-contraction functions to brace a joint and isn’t necessarily unhealthy. But previous research has found that individuals with knee osteoarthritis often use excessive co-contraction in their leg muscles during walking and other everyday activities. In this study, the subjects with knee osteoarthritis showed significantly higher levels of co-contraction in their leg muscles than the healthy control group as measured by EMG at the start of the study.

After Alexander

In the study, the 21 participants with knee osteoarthritis had 20 Alexander Technique lessons. The lessons were spaced out over 12 weeks: they had lessons twice a week for 8 weeks and then once a week for the final four weeks.

After their Alexander lessons, the participants showed a dramatic reduction in pain: 56% less pain than at the start of the study. 15 of the study participants regularly took pain killers (analgesia) at the start of the study. 10 stopped taking medication after their Alexander lessons ended. 11 of the participants also reported experiencing less pain in other areas, including neck, shoulder and back.

The subjects also exhibited significantly less co-contraction during walking than at the start of the study. Interestingly enough, the patients did not show an increase in strength over the course of the study—the measurements of leg strength were the same before and after their Alexander lessons.

None of the subjects used any other therapy during their Alexander Technique study. When the researchers followed up 15 months after the start of the study, the subjects had retained the reductions in pain, reporting 51% less pain than before their Alexander lessons.

Evidence & Measurement

We are living in an increasingly “evidence-based” world. Evidence depends on valid and reliable measurement. Alexander teachers have learned that their experience and the experience of their students isn’t considered very robust evidence for scientists studying health and movement. However compelling the anecdote—of pain diminished, increased ease, health restored—saying, “I saw it happen” or “It happened to me,” doesn’t really count.

Most studies of the effectiveness of a particular health intervention use some kind of self-report. For the current study, the subjects filled out the WOMAC questionnaire—a common tool used to evaluate knee and hip pain, stiffness and functioning—before and after their Alexander lessons. It’s on the basis of that self-report that we can say that pain was reduced 56% by Alexander Technique lessons. This kind of self-report is quite a bit more reliable than anecdotal data, but researchers are always looking for other sources to corroborate self-report. Bias too easily creeps in.

The advantage of basic research is the chance to experiment with different types of measurement. With only 21 subjects, the researchers can hook them up to EEG to try to measure the anticipation of pain. They can measure muscle activity with EMG and put the subjects on a force platform to assess joint loading. This kind of laboratory research is much more time intensive and expensive than having someone fill out a questionnaire.

The results of the study suggest that this kind of EMG measurement is worth it in studying the effects of AT on knee pain and osteoarthritis. The researchers found that the self-reported reduction in pain was correlated with a measurable change in the subjects movement coordination—a physiological change in the activity of their musculature. It points in a promising direction, both for scientists who study human motor control and the causes of musculoskeletal pain, as well as doctors who treat knee osteoarthritis. And it might even inspire one of those large randomized control trials to see if the findings hold up in the messy world of clinical medicine.

Many thanks to Tim Cacciatore, one of the authors of the current study, for his feedback on an earlier draft of this post.

A new study published in the Annals of Internal Medicine shows a significant reduction in chronic neck pain after lessons in the Alexander Technique.

517 patient with chronic neck pain were assigned to one of three groups. The control group received the usual care: physical therapy and prescription drugs. A second group was assigned 20 one-on-one, 30-minute Alexander Technique lessons (600 minutes total) with a certified teacher. The third group was assigned to 12 acupuncture sessions (also 600 minutes total). On average, patients made it to 14 of their 20 Alexander lessons and 10 of their 12 acupuncture sessions.

Patients taking Alexander Technique lessons and those receiving acupuncture both experienced more than a 30% reduction in their chronic neck pain. A 25% reduction in pain is considered clinically significant. As Time points out in their coverage of the study, physical therapy and exercise lead to only about a 9% reduction in pain.

The most important result from the study is that the benefits of Alexander lessons persisted after lessons had ended. Patients completed their Alexander lessons in about 4 to 5 months after the start of the study. A year after the beginning of the study the patients were still experiencing a reduction in pain.

Stuart McClean at the University of the West of England in Bristol discussed the study with Reuters Health and suggested that the Alexander Technique helps “patients change past behaviors and habits and lead towards improved coping strategies and self-care.”

The lead author of the study, Hugh McPherson, explained that the results of the study were too robust to be the result of the placebo effect. And none of the participants in either Alexander Technique lessons or acupuncture sessions experienced adverse effects of any kind. “No other single treatment is known to provide long-term benefits,” Hugh McPherson told Reuters.

These kind of large, randomized studies of the Alexander Technique are rare. This is the first study of its kind to be published since the ATEAM study of back pain published in the British Medical Journal in 2008. That study found that back pain sufferers experienced significant relief from as few as 6 Alexander Technique lessons.

Such studies are confirming what Alexander Technique teachers have been teaching for 100 years: learning to improve your posture and movement habits can have a significant impact on your health.

I picked up my music last week for Newsies, a touring Broadway show that’s coming to Chicago to start a month long run on December 10th. It got me thinking about the first show that I played in town three years ago: Stephen Sondheim’s Follies at the Chicago Shakespeare Theater. It nearly killed me.

I’d been freelancing in Chicago for seven years when I got called to play Follies. The life of a freelance musician can be very feast or famine, so the prospect of solid work for six weeks was exciting. When I say it’s solid work, I actually mean it’s a lot of work: eight to nine shows a week, with only Mondays off. That means double performances on Wednesdays and Saturdays, sometimes Sundays. I knew I was going to be tired, but I was pretty confident that my Alexander training had given me the know-how to get through all the performances intact and healthy.

The first couple of band rehearsals went well. When we joined the cast for the sitzprobe we were on stage for the first time. Follies tells the story of a reunion of old theater performers, and the director Gary Griffin had decided to put the musicians on stage with the actors, so that we seemed like the reunion band. Space was pretty tight: the band was terraced up the back of the stage. I was down on the lowest terrace between Ben on harp and Jill on cello. There wasn’t a lot of space between my music stand and my chair. I had to sit back in the chair in order not to be straddling the music stand with my legs.

It wasn’t a great chair. It was sturdy enough, but the seat sloped backward. That wasn’t ideal—it’s hard to be poised on your sit bones if your chair slopes back. The chair was a little low for me and the cushion, though firm, was thick: my butt sank into it so that my hips were below my knees. The worst part, though, was the back, which was on a spring hinge, and would lean further back if you put your weight on the back of the chair. I didn’t like the fact that I couldn’t rest against the back of the chair without going into recliner mode. But I was an Alexander teacher—I knew how to sit in a chair. Didn’t Alexander himself say something like (and I’m paraphrasing), “We educate people, not furniture.” Plus, this was my first show. I didn’t want to be that guy, complaining about his chair.

We had a dress rehearsal on Tuesday afternoon and then our first preview performance Tuesday night. Afterwards, my back was pretty achy. The next day we had two previews and after the second show I was in bad shape. My back did not feel good. I limped back to my car, feeling old.

I knew that I was probably playing a little tight—it was my first show, after all. But I wasn’t particularly nervous or stressed out. Yet by the end of the Thursday show, my back was hurting like it had never hurt before, a dull ache that wouldn’t quit. I had a friend visiting from out of town, and after the show all I could do was lie on the floor on my back and wonder how it could possibly be so bad. I was not being a good host.

It wasn’t just my back that hurt. My ego was taking a bruising, too. I was an Alexander teacher. I’d been studying the Technique for 12 years. I had been a certified teacher for 8 years. As a teacher, I had helped students overcome back pain. And here I was, three performances into my first run of a show and my back hurt so much I couldn’t stand. I was a fraud.

I did everything I knew how to do. When I practiced during the next day, I stood up to stay mobile. I did lots of lie-downs. I was going to keep it together. But three quarters of the way through the next show, my back was hurting so much it felt like it was going to give out. Halfway through Losing My Mind, I was thinking, “I’m going to lose MY mind if my back hurts like this for the next six weeks.”

Like I said the chair was cushioned, but the front lip of the chair had a metal bar running underneath the cushion. In desperation, I sat up on the front of chair, so close to my music stand that I was in danger of knocking it over with each down bow. But as soon as my butt touched the solid support of the chair’s edge, I felt this connection shoot up my spine from my sit bones to my head. The relief to my back was instantaneous.

The Stefan chair: nothing special, but it gets the job done.

I also looked a little ridiculous. For the rest of the show, I played sitting on the lip of the chair, looking like I was about to embrace the music stand. After the show I went to Bruce, the Stage Crew Supervisor, and told him I needed to swap out my chair. There weren’t any other options at the theater, so I brought one of my simple black Stefan chairs from home. As tired as I got as the run went on, my back didn’t hurt again. The run turned out to be an amazing experience. I made some of the closest friendships I’ve made in Chicago. And we had the unexpected excitement of performing for Stephen Sondheim himself at one of our final performances.

As an Alexander teacher, I prided myself on my ability to sit in any chair. But my experience with Follies showed me that there are certain circumstances where I don’t want to have to fight my furniture while doing my job. Playing a show eight times a week is tiring enough without having to compensate for a terrible chair.

I’ve now played three shows at Chicago Shakespeare Theater and have a new way of setting up my station. By stacking two of the theater’s chairs, you get extra-height, the seat becomes level, and the back doesn’t push back as much when you lean against it. Tape the legs together and the chair is secure for the rest of the run. It’s even better than my Stefan chair. I don’t know what chair will greet me when I get to the Oriental Theater for the first rehearsal of Newsies in little over a week. But I’m no longer worried about being that guy. If they don’t have a chair that will work for me, I’m happy to bring my own.

Recently my Facebook feed has blown up with articles and news segments about the dangers of “text neck.” It turns out that spending hours a day hunched over your smartphone texting is a bad idea and leads to all sorts of neck and upper back issues. Who knew? The news stories have given some good counsel—like limiting the amount of time you spend on your phone and moving your body in ways that are different than hunching over a phone. But as I’ve read the advice about preventing “text neck,” I keep wondering, do we give ourselves any choice in the matter?

I was reminded of a student who came to me for Alexander Technique lessons several years ago, just before the smartphone revolution. He was a doctor complaining of neck pain. He tried to set up regular lessons, but like many doctors, his schedule was not entirely his own. Even when we managed consistent lessons, he was always on call. With most of my students, I ask that they leave their phones off so that we can work without interruption. But he had to leave his pager on, just in case he had to respond to an emergency at the hospital.

I have to admit, he was a challenging student. At the start of each lesson, he would fill me in with a detailed report on his neck symptoms at work. He monitored himself ceaselessly to see if there was any improvement. He was obsessed with finding the “correct way to move” and gave himself detailed instructions using his voluminous knowledge of human anatomy. He would inform me, “I need to tone up through the erector spinae group, widen through the trapezius and release into the quads.” I suggested that he not micro-manage his movements, and told him the parable of the centipede who tried to control all one hundred legs consciously and ceased to be able to walk at all. I tried to convince him that the first step was to leave himself alone. He needed to practice “non-doing:” it would give him a chance to observe himself and see if he could discover if his movement habits contributed to his neck problem.

One lesson I finally succeeded in getting him to stand quietly, leaving himself alone. I had just placed my hand where his head meets his neck and was helping him experience a “free neck”—moving his head gently back and forth in the “no” direction—when his pager went off. At the sound of the buzzing, his neck tensed dramatically, the back of his head pulled back, and his shoulders went up around his ears.

He duly checked his pager—it was not an emergency. We looked at each other. “I think we know why you have some neck tension,” I said.

‘Push notifications’ inform us not only of texts or phone calls, they alert us to e-mail, Facebook status updates, tweets, breaking news, traffic reports, weather alerts, and the latest available level on Angry Birds Star Wars II. Our response becomes habitual. The alert sounds and we jump into action. If that habit includes pushing our head forward 30 degrees, we may not even notice our necks tense to carry the 40 lbs of functional weight. That’s the thing about habits: they are unconscious and automatic.

The head is a heavy object. The average head weighs about 10 pounds. When your neck is free and the head is poised on a lengthening spine, it has a functional weight of 10 pounds. But for every degree the head is held forward—whether towards a cell phone, a computer, a book, a music stand, or a musical instrument—its functional weight increases dramatically. As this study by Kenneth K. Hansraj found, a 10 pound head held 30 degrees forward has a functional weight of 40 pounds.

So what we do with our heads has an enormous impact on the health of our necks, shoulders and backs. With my doctor student, the anxiety around the insistent and unbidden summons of his pager caused a spasm of tension in his neck, jerking his head back into his spine. The action was particularly dramatic in his Alexander lesson because it happened right after I had helped him find length in the neck and freedom at the head-neck joints. In his everyday life, though, he rarely freed his neck and it became increasingly tense and painful throughout the week.

Smartphones and doctors' pagers are similar in one important respect: they are stimulus response-machines. And smart phones are even more stimulating: "push notifications” inform us not only of texts or phone calls, they alert us to e-mail, Facebook status updates, tweets, breaking news, traffic reports, weather alerts, and the latest available level on Angry Birds Star Wars II. Our response becomes habitual. The alert sounds and we jump into action. If that habit includes pushing our head forward 30 degrees, we may not even notice our necks tense to carry the 40 lbs of functional weight. That’s the thing about habits: they are unconscious and automatic.

But there’s a key difference between doctors' pagers and our smartphones. Doctors are required to have a pager and may even, like my former student, resent its constant thrall. But if you’re anything like me, you love your smartphone. In fact, you could say that the stimulus from within—”I wonder what my friends think of that cat photo I just posted on Facebook,” for example—is as strong as the push notification from without.

Understanding the power of habit is as important in preventing “text neck” as limiting our time on our phones—maybe more so, since so many of us enjoy the time we spend on our phones and don't have any intention of reducing it down. With my doctor student, we practiced a different response to his pager: when it sounded, he would remind himself to pause, take his time in responding, free his neck. We can do the same thing with our phones. The next time in pings, we can give our necks a break. We can take a moment, however fleeting, and do nothing.

This is the first in a six-part series about my experience studying the Alexander Technique for the first time.

I had just graduated from Oberlin and pain was on my mind. I wasn’t injured, but I figured it was just a matter of time.

I’d watched many of my peers take time off from playing because of injury, usually tendonitis. One friend imploded in spectacular fashion. She was having hand problems, yet still practiced 7 to 9 hours a day. Her doctor father sent her prescription codeine so she could practice through the pain. The day came when she couldn’t play any more and she realized she would have to rehabilitate her hands. She did start to recover, but at a certain point she felt she’d lost too much time, and gave up her aspirations to perform.

I took it as a cautionary tale. If I felt a twinge in the practice room, I would go home for the day. I was supposed to be practicing 4 to 6 hours a day, but if I felt discomfort after 45 minutes, I would pack it in.

As a result, I was never injured, but discomfort was pretty constant—and often mysterious. Before my junior recital, I had some spasms in the muscles beneath my shoulder blades. What was that all about? One winter term I took a contact improv class (because: Oberlin) and at the start of class we would stretch for an hour. As I stretched, I would feel the tightness in my wrists slowly unfurl. After class I would go practice for a few hours and the next morning the tightness in my wrists would be back.

I may not have had a pain problem, but I definitely had a problem with pain. If I hurt, I didn’t know why I hurt, or what I could do about it. A life in music seemed to mean accepting a life with a certain amount of pain.

That fall I moved to Minneapolis to study with Jorja Fleezanis, then concertmaster of the Minnesota Orchestra. A question dominated my mind: how can I practice enough to be a professional musician and not get injured?

I may not have had a pain problem, but I definitely had a problem with pain. If I hurt, I didn’t know why I hurt, or what I could do about it. A life in music seemed to mean accepting a life with a certain amount of pain.

The question became even more urgent when I started watching the Minnesota Orchestra play. Jorja was generous with tickets to see the orchestra. I had seen orchestras perform before, but I had never seen an orchestra perform every week. I was staggered by the amount of rep they tore through, not only a new program each week, but a new and challenging program every week. It was physically and mentally demanding beyond anything I had experienced as a student.

Jorja was always taking her students out for dinner after concerts. One night, I finally asked: how are you not in pain? How do you avoid injury? Do you stretch? Yoga? Massage? What?

She said that she had studied the Alexander Technique for six years and that she had learned to sit and to move in ways that didn’t wear on her body. I have a memory of her standing in the restaurant and putting her hands on her hips and talking about finding the connection from the back to the hips to the chair when she played.

It’s hard to overstate the influence of a trusted teacher. I’ve sometimes thought that if Jorja had said she avoided injury by bungee jumping I would have grabbed a cord and leapt off the nearest bridge. That winter, when I came back to Minneapolis after the holiday break, I decided to find a teacher. I was fortunate to find Carol McCullough. I remember our first conversation. “I’m a violist,” she told me. “There’s a lot I can show you.”

This isn’t the time to go into all the insights I gained from my first lessons with Carol. But I often reflect about my early beliefs on being a musician and the inevitability of injury. I think many musicians share the kind of pain problem I had as a conservatory student: they defer a true commitment to the work it takes to be a performer out of fear of injury. Through those first Alexander lessons, I was able to put that fear to rest. Carol showed me a way of working that both reduced the risk of injury and renewed my joy in playing. It’s a way of working that is available to anyone.

Next: Off the Map, in which I discover I have no idea where I am in a very fundamental way.